Engagement vital to Indigenous sexual health

COMMUNITY engagement and continuity of care are key to the high uptake and acceptability of long-acting reversible contraceptives (LARCs) in several remote Aboriginal communities in the Western Desert region, says the lead researcher of a study published in this week’s MJA. 

Dr Emma Griffiths, a GP with the Kimberley Aboriginal Medical Services Ltd in WA, said the positive results reflected a service model that prioritised community engagement and holistic care.

“How that feels and looks on the ground is a lot about continuity of care,” Dr Griffiths told MJA InSight. “We have found from having the same person in the job for a long period of time – which can be pretty difficult to achieve in itself in remote areas — has been a success story of this program.

“The engagement of the community on a one-on-one level creates a sense of trust between the service providers and the community, and this has been one of the big achievements of the program,” Dr Griffiths said.

• Related: MJA — Uptake of long-acting, reversible contraception in three remote Aboriginal communities: a population-based study
• Related: MJA — Access to contraception for remote Aboriginal and Torres Strait Islander women: necessary but not sufficient
• Related: MJA InSight — Roxanne Bainbridge & Janya McCalman: Culture matters
• Related: MJA — High chlamydia positivity rates in Indigenous people attending Australian sexual health services

The mixed method study used retrospective file review as well as semi-structured interviews to determine the uptake and acceptance of contraceptive options between 2010 and 2014 in three remote Aboriginal communities in the Kimberley region of WA.

Of the 566 patients included in the study, 34% had used a contraceptive during the study period. LARCs were the most commonly used contraceptive type, with 77% of women using contraception at the census date opting for etonogestrel implants and 7% choosing depot medroxyprogesterone.

Continuation rates were in line with other populations at one year, with 87% continuing use of the etonogestrel implant at 1 year (95% CI, 81–92%), then 72% at 2 years (95% CI, 64–78%) and 51% at 3 years (95% CI, 41–60%). Medroxyprogesterone depot continuation at one year was only 14% (95% CI, 8-22%).

Following interviews with 20 women, the researchers also reported a high social acceptance of LARCs, with no concerns raised about stigma or unwanted attention related to implant use.

Several factors contributed to the program’s success, including increased GP workforce consistency, with a fulltime locally based GP from 2011, and the employment of a dedicated sexual health coordinator for the three communities from early 2013. Local nursing staff were also upskilled to perform Pap smears and to insert and remove etonogestrel implants.

Dr Griffiths noted that various forms of community engagement were employed in the program, including communicating health messages through art, dance and story-telling.

“Community members produced art that was meaningful to them in terms of relationships, bringing together health messages and stories about relationships,” she said. 

Dr Deborah Bateson, senior medical spokesperson for Family Planning Alliance Australia, applauded the “whole-of-community” approach to the provision of sexual and reproductive health care in the remote region.

“This is very good news,” Dr Bateson told MJA InSight. “It’s absolutely essential that we have this whole-of-community approach to sexual and reproductive health that promotes positive sexual health.”

She said community engagement, as well as the involvement of a locally based GP, Aboriginal health workers and nurses trained in LARC insertion seemed to be pivotal to the program’s success.

Dr Bateson said Australia was lagging behind many countries in the use of LARCs, but this study had shown that the method had high acceptability in this population. 

“It’s really important for practitioners to read papers such as this to see there are good news stories in that women are choosing these LARC methods and, most importantly, they’re continuing them,” she said.

In an accompanying editorial, Professor Sarah Larkins and Ms Priscilla Page of James Cook University said the study was “a welcome addition to our understanding of the uptake of contraception and of attitudes among Aboriginal women”. “For all young women, access to contraception is only one part of comprehensive sexual and reproductive care,” they commented.

“This care needs to be embedded in a holistic primary health care system providing culturally appropriate support, and must include attention to the broader social determinants of health.”

Dr Griffiths agreed that sexual and reproductive health had far wider implications for a community. “It’s more than simply about contraception, and STIs,” she said.

“We are just trying to contribute another piece of the puzzle here, but the answer lies in holistic sexual and reproductive programs that support autonomy and life opportunities for women.”

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